Mortons Neuroma

Lower Limb

Overview

Morton's neuroma is a benign enlargement of a plantar digital nerve, typically occurring in the third or fourth intermetatarsal space of the foot. The condition results from chronic compression and irritation of the nerve, leading to fibrosis and neurogenic pain. It presents with sharp, burning pain in the forefoot and is a common cause of metatarsalgia in active individuals.

Pathophysiology

Morton's neuroma develops through chronic compression of the plantar digital nerve as it passes between the metatarsal heads. Repetitive trauma, often from activities involving forefoot loading or constrictive footwear, causes inflammation and fibrosis of the nerve sheath. The nerve becomes entrapped and ischemic, resulting in demyelination and nerve hypertrophy. Mechanical irritation between adjacent metatarsal heads perpetuates the condition, leading to characteristic neurogenic pain with potential referred symptoms into the toes.

Typical Presentation

Site

Third or fourth intermetatarsal space (between 3rd-4th metatarsal heads most common), radiating into the plantar aspect of the forefoot and adjacent toes

Quality

Sharp, burning, electric, tingling, or numb sensation; often described as 'walking on a marble' or 'like a nerve is being pinched'

Intensity

Mild to severe, typically worsens throughout the day; intensity 3-8/10 depending on activity level

Aggravating

Walking barefoot or in tight shoes, high heels, forefoot-loading activities, standing for prolonged periods, pushing off during gait, pressure over the intermetatarsal space

Relieving

Rest, removing shoes, massage of the affected area, ice application, anti-inflammatory medications, flat shoes with wide toe box, metatarsal support

Associated

Metatarsalgia, toe numbness or paresthesia, referred pain to adjacent toes, altered gait pattern, reduced push-off phase, callus formation under metatarsal heads, positive Mulder's sign (click on compression between metatarsals)

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

Contested
Reported accuracy varies widely across studies — may be strong or weak depending on population and technique
Evidence is highly heterogeneous: reported figures span from a weak (C) to a strong (A) test across studies/populations. Interpret with caution and in context.

Mulder's Click Test

Procedure

Patient supine. Squeeze the metatarsal heads together with one hand while pressing up into the plantar web space (usually between the third and fourth toes) with the thumb of the other hand.

Positive Finding

A palpable (sometimes audible) click in the web space, often reproducing the familiar pain or tingling into the toes.

Sensitivity / Specificity

29–94% (3 studies)/87% (1 study, 23 people without a neuroma)

Reference: Pitcher M, Moulson A, Pitcher D, Herbland A, Cert G, Cairns MC. Diagnostic Accuracy of Subjective Features and Physical Examination Tests for Morton Neuroma: A Systematic Review. Foot Ankle Orthop. 2024;9(4):24730114241291055.

Interpretation

A click with the familiar symptoms supports a Morton's neuroma. A patient who reports clicking in the forefoot is also a helpful sign. Ultrasound confirms the diagnosis when injection or surgery is being considered. From a 2024 systematic review (Pitcher et al.) of 9 studies. Most studies included few or no people without a neuroma, so specificity could only be calculated from one study (Dando, 30 patients with forefoot pain, ultrasound reference). A positive click supports a neuroma; a patient reporting clicking themselves was also a useful sign in that review.

Sources

No accuracy study

Metatarsal Squeeze Test (Foot Squeeze)

Procedure

Patient supine or seated. Squeeze the forefoot from side to side across the metatarsal heads.

Positive Finding

Reproduction of the familiar forefoot pain or tingling into the adjacent toes.

Sensitivity / Specificity

42–88% (3 studies)/—

Interpretation

Supports a neuroma but also provokes pain from other forefoot problems (metatarsalgia, stress fracture, joint synovitis), so a positive result is not specific. Pain localised to one web space and spreading into the toes is more suggestive of a neuroma. From a 2024 systematic review (Pitcher et al.) of 9 studies. Most studies included few or no people without a neuroma, so specificity could only be calculated from one study (Dando, 30 patients with forefoot pain, ultrasound reference). The studies of the squeeze test had almost no people without a neuroma, so no specificity is shown. (This test was previously mislabelled "Lachman's", which is a knee ligament test.)

Sources

  • RelatedPitcher M, Moulson A, Pitcher D, Herbland A, Cert G, Cairns MC. Diagnostic Accuracy of Subjective Features and Physical Examination Tests for Morton Neuroma: A Systematic Review. Foot Ankle Orthop. 2024;9(4):24730114241291055.

Further reading

No accuracy study

Gauthier's Test

Procedure

Squeeze the metatarsal heads together and move them up and down against each other for about 30 seconds.

Positive Finding

Reproduction of the familiar burning or tingling into the affected toes.

Interpretation

Another provocation test for Morton's neuroma. Not well studied; use it with Mulder's click and web space tenderness. A 2024 systematic review of 9 studies of Morton's neuroma (Pitcher et al.) found no study of Gauthier's test, so no figure is shown. The best-supported test is web space tenderness on a thumb-and-finger squeeze: it was positive in 68–100% of confirmed neuromas, so a negative squeeze makes a neuroma less likely. Few of the studies included people without a neuroma.

Sources

  • RelatedPitcher M, Moulson A, Pitcher D, Herbland A, Cert G, Cairns MC. Diagnostic Accuracy of Subjective Features and Physical Examination Tests for Morton Neuroma: A Systematic Review. Foot Ankle Orthop. 2024;9(4):24730114241291055.

Further reading

No accuracy study

Tinel's Sign (Intermetatarsal)

Procedure

Tap gently over the plantar web space between the affected metatarsal heads.

Positive Finding

Tingling spreading into the adjacent toes.

Interpretation

Suggests an irritated interdigital nerve at that point. Not well studied; use it with the other forefoot tests. A 2024 systematic review of 9 studies of Morton's neuroma (Pitcher et al.) found no study of Tinel's sign itself. Percussion over the web space, which is similar, was positive in 36% and 61% of confirmed neuromas in two studies, so a negative result does not rule a neuroma out. Almost no people without a neuroma were included, so specificity is unknown.

Sources

  • Educational sitePhysiopedia. Tinel's Test.
  • RelatedPitcher M, Moulson A, Pitcher D, Herbland A, Cert G, Cairns MC. Diagnostic Accuracy of Subjective Features and Physical Examination Tests for Morton Neuroma: A Systematic Review. Foot Ankle Orthop. 2024;9(4):24730114241291055.
No accuracy study

Web Space Tenderness and Reproduction Test

Procedure

Palpate each plantar web space between the metatarsal heads, and each metatarsal head, and compare.

Positive Finding

Tenderness in one web space (between the heads) rather than over the heads themselves.

Interpretation

Tenderness between the metatarsal heads points to a neuroma or intermetatarsal bursitis; tenderness over a metatarsal head points to metatarsalgia, joint synovitis or a plantar plate problem. From a 2024 systematic review (Pitcher et al.): web space tenderness picked up 94% of neuromas in one study (Cloke) and 57% in another (Dando). In the only study with a real comparison group (Dando: 30 people with forefoot pain, ultrasound reference, 23 without a neuroma), it was also positive in 70% of those without a neuroma, so tenderness alone does not separate a neuroma from other forefoot pain. No figure is shown.

Sources

No accuracy study

Thumb–Index Finger Web Space Squeeze

Procedure

Squeeze the affected web space between your thumb on the sole and your index finger on the top of the foot, just behind the toes.

Positive Finding

Sharp pain or reproduction of the familiar symptoms in that web space.

Sensitivity / Specificity

68–100% (4 studies)/—

Interpretation

Pain localised to one web space supports a neuroma or an intermetatarsal bursitis in that space. Use it with Mulder's click and the history (burning or tingling into two adjacent toes, eased by taking the shoe off). From a 2024 systematic review (Pitcher et al.): this squeeze (the "modified web space tenderness test") picked up 68–100% of neuromas in 4 studies. Those studies included at most one person without a neuroma, so no specificity can be calculated. The review's claim that a negative test rules a neuroma out rests on that single person, so treat a negative result as reassuring rather than conclusive.

Sources

⚠ Red Flags

  • •Signs of cellulitis or infection (redness, warmth, systemic fever)
  • •Severe neurovascular compromise (color changes, cold foot, absent pulses)
  • •Traumatic foot injury with severe swelling or deformity
  • •Unilateral foot swelling with calf pain (DVT risk)
  • •Symptoms of cauda equina or conus medullaris
  • •Progressive neurological deficit with loss of motor function

⚡ Yellow Flags

  • •Chronic pain behavior with excessive focus on symptoms
  • •High anxiety or catastrophizing about foot pain
  • •Occupational stress combined with prolonged standing
  • •Maladaptive gait patterns developed to avoid pain
  • •Multiple pain sites or pain amplification syndrome
  • •Psychosocial barriers to exercise participation
  • •Excessive reliance on footwear modifications alone

Osteopathic Techniques

Start with footwear (wide, soft-soled and low-heeled) and a metatarsal pad placed just behind the metatarsal heads; injections come next. Manipulation or mobilisation and corticosteroid injection have the strongest evidence for pain relief, though no high-quality trials exist.

Region

Metatarsophalangeal and intermetatarsal joints

Technique

Articulation, ankle and foot
Grade C
Limited evidence: indirect or low-quality support only
A review found manipulation or mobilisation reduced pain more than control. With steroid injection it has the strongest evidence, but no high-quality trials exist.

Rationale

Ankle, subtalar and midfoot glides, mainly to restore dorsiflexion and foot mobility.

How it's done, cautions & evidence

How it's done

Passive, rhythmic, low-velocity glides of the ankle (talocrural), subtalar, midfoot and toe joints, within or up to the end of the available range, often aimed at restoring ankle dorsiflexion.

Cautions

Before mobilising an acute ankle injury, check for fracture with the Ottawa ankle rules (tenderness over either malleolus), and palpate the base of the 5th metatarsal, the navicular and the midfoot for a Lisfranc injury.

Evidence in Mortons Neuroma

Matthews 2019 (SR/MA, 25 studies including 7 RCTs): manipulation/mobilisation reduced pain versus control (MD −15.3, 95% CI −29.6 to −1.0). Corticosteroid injection and manipulation/mobilisation had the strongest evidence for pain reduction, but no high-quality evidence for a gold-standard treatment was found.

Region

Plantar foot and intermetatarsal spaces

Technique

Soft tissue, foot and ankle
Grade D
Low evidence: expert consensus or could not be verified against literature
No controlled trials of soft tissue technique in Morton neuroma. StatPearls lists massage among the non-operative options.

Rationale

Soft tissue to the plantar fascia, foot muscles and the tissues around the heel and ankle ligaments.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the plantar fascia, the small muscles of the foot and the tissues around the heel and the ankle ligaments.

Evidence in Mortons Neuroma

Searched 25 Oct 2026: no controlled trials. Indirect: StatPearls (Morton Neuroma) lists massage therapy among non-operative options, after footwear and metatarsal padding.

Region

Gastrocnemius-soleus (calf and Achilles)

Technique

Muscle energy, calf (gastrocnemius and soleus)
Grade D
Low evidence: expert consensus or could not be verified against literature
No trials in Morton neuroma. StatPearls recommends calf and Achilles stretching to cut forefoot pressure from a tight calf (equinus).

Rationale

Calf muscle energy technique to ease gastrocnemius-soleus tightness that limits ankle dorsiflexion.

How it's done, cautions & evidence

How it's done

The calf is taken to its barrier by dorsiflexing the ankle. The patient pushes the foot gently down, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.

Cautions

Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.

Evidence in Mortons Neuroma

Searched 25 Oct 2026: no trials. Indirect: StatPearls (Morton Neuroma) recommends stretching the calf–Achilles complex to reduce forefoot pressure from equinus.

Rehabilitation Exercises

Ankle Dorsiflexion and Plantarflexion (Seated)

Range of MotionBeginner

Seated Calf Stretch with Towel or Band

StretchingBeginner

Plantar Fascia Stretch Using Towel Roll

StretchingBeginner

Short Foot Exercise (Intrinsic Foot Muscles)

StrengtheningBeginner

Towel Scrunch or Marble Pickup (Plantar Intrinsics)

StrengtheningBeginner

Toe Spreading Exercise (Abductor Digiti Minimi)

StrengtheningBeginner

Single Leg Stance on Firm Surface

BalanceIntermediate

Calf Raises (Standing or Wall Support)

StrengtheningIntermediate

Standing on Foam Pad with Weight Shift

BalanceIntermediate

Gait Retraining: Midfoot/Heel Strike Pattern

PosturalIntermediate

Single Leg Calf Raises (Advanced Balance and Power)

StrengtheningAdvanced

Swimming or Aquatic Walking (Low Impact Conditioning)

CardiovascularIntermediate

Referral Criteria

  • •Failure to improve after 4-6 weeks of conservative management including footwear modification and exercises
  • •Severe, progressive neurological symptoms (loss of sensation, motor weakness) suggesting significant nerve compromise
  • •Signs of infection or cellulitis in the forefoot requiring medical evaluation
  • •Suspicion of alternative diagnosis (stress fracture, joint capsulitis, synovitis) based on clinical examination
  • •Need for diagnostic imaging (ultrasound or MRI) to confirm diagnosis or rule out differential diagnoses
  • •Consideration of injectable interventions (corticosteroid injection) requiring medical practitioner authorization
  • •Surgical candidacy assessment if conservative measures fail (patient to GP or foot specialist for evaluation)
  • •Vascular insufficiency or significant comorbidities affecting healing capacity